Child Support Summary Form
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2UCS-111 (rev:08/11)
CHILD SUPPORT SUMMARY FORM
SUPREME COURT
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COMPLETE FORM FOR EACH BASIC CHILD SUPPORT OBLIGATION ORDER
A. Court:
Supreme
K. If answer to “J” was yes, circle court's reason(s):
1. Financial resources of parents/child.
B. County:
2. Physical/emotional health of child:
special needs or aptitudes.
C. Index #:
3. Child's expected standard of living had
household remained intact.
D. Date Action Commenced:
4. Tax consequences.
/
/
5. Non-monetary contribution toward care and
E. Date Judgment/Order Submitted or Signed:
well-being of child.
6. Educational needs of either parent.
/
/
7. Substantial differences in gross income of
parents.
F. # Of Children Subject to Child Support Order:
8. Needs of other children of non-custodial
parent.
9. Extraordinary visitation expenses of non-
G. Annual Gross Income:
custodial parent.
1. Plaintiff: $
Defendant: $
10. Other (specify):
H. Amount of Child Support Payment:
1. By Plaintiff: $
2. By Defendant: $
annually
annually
L. Maintenance/Spousal Support:
(Circle one)
I. Additional Child Support:
(Circle as many as appropriate)
1. None
2. By Plaintiff
3. By Defendant
By Plaintiff:
By Defendant:
M. Value of Maintenance/Spousal Support:
$
annually
1. Medical/Med. Ins. 1. Medical/Med. Ins.
2. Child Care
2. Child Care
SUPREME COURT ONLY
3. Education
3. Education
4. Other
4. Other
N. Allocation of Property:
% To Plaintiff
% To Defendant
J. Did the court make a finding that the child
support award varied from the Child Support
Standards Act amount? (Circle one)
1. Yes
2. No
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Defined by FCA 413(2) and DRL §240(1-b)(b)(2): “Child Support” shall mean a sum to be paid pursuant to court order or decree
by either or both parents or pursuant to a valid agreement between the parties for care, maintenance and education of any unemancipated child
under the age of twenty-one years.
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